BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 06/04/2010

Date of Order : 29/10/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 211/2010

Between

And

O R D E R

A. Rajesh, President.

1. Briefly stated, the case of the complainant is as follows :

The complainant is the holder of a mediclaim policy of the 1^st opposite party. He had submitted two claims for Rs 522/- and Rs. 1,025/- on 21-02-2001 with respect to the treatment received by him at Lourdes Hospital for renal calculi from 16-02-2009 to 17-02-2009. But the claim was repudiated by the 2^nd opposite party by their letter dated 21-04-2009. The reason for repudiation is that the pre and post hospitalisation limit for one illness is payable maximum upto 10% sum insured which paid already in cashless claim. The above said reason given for repudiation is not sustainable. The claim preferred by the complainant for Rs. 1,025/- dated 21-02-2009 is with respect to the inpatient treatment and the complainant never exceed the 10% sum insured limit. The complainant is entitled to get Rs. 1,647/- with interest at the rate of 12% per annum together with costs of the proceedings. This complaint hence.

2. Version filed by the 1^st opposite party :

The complainant is the holder of mediclaim policy for the period from 09-05-2008 to 08-05-2009. The claim of the complainant is on 16-02-2009, i.e. the claim is not with regard to the above mentioned policy. In the complaint, it is mentioned that the complainant had submitted the claim on 21-02-2004, the treatment received on 16-02-2009 to 17-02-2009. So the complainant has no consistent case. The complainant has not submitted any claim before the opposite party. He has not admitted in the hospital for the treatment undergone as mentioned in the complaint. There should be 24 hours hospitalisation as per the policy conditions to prefer a claim. The 1^st opposite party is not liable to the claim as mentioned in the complaint.

3. In spite of service of notice from this Forum, the 2^nd opposite party opted not to contest the matter for their own reasons. No oral evidence was adduced by the complainant. Exts. A1 and A2 were marked on his side. Neither oral nor documentary evidence was adduced by the 1^st opposite party. Heard the counsel.

4. The points that arose for consideration are :-

1. Whether the complainant is entitled to get insurance claim from the opposite parties?

2. Costs of the proceedings?

5. Point No. i. :- Admittedly, the complainant was holding mediclaim policy for the period from 09-05-2008 to 08-05-2009. The complainant submitted claim application before the opposite parties for his treatment from 16-02-2009 to 17-02-2009 at Lourdes Hospital, Ernakulam for Renal Calculi.

6. The opposite parties repudiated the claim for the reason stated in Ext. A2 repudiation letter which reads as follows :

“As per pre and post hospitalisation limit for any one illness is payable maximum upto 10% of sum insured which is paid already in cashless claim.”

Admittedly, the sum insured of the complainant is Rs. 50,000/-. According to the opposite party, the pre and post hospitalization for any one illness is payable upto 10% of the sum insured. Ext. A1 goes to show that the claim of the complainant is only Rs. 622/- and Rs. 1,025/- respectively which is squarely within the limits as stated by the opposite party.

7. Point No. ii. :- Seemingly, it is stated that the practice of the 1^st opposite party even when having no case to fight the same. This Forum has had such many occasions of the authorities concerned would be aware of such a nature of precedents much controversies or litigation could be avoided. All is not lost but we hope for the better.

8. We are at a loss as to why such a legitimate claim has been dishonoured for no legitimate reasons. This Forum holds that the 1^st opposite party is liable to pay the insurance claim with interest.

9. In the result, we partly allow the complaint and direct that, the 1^st opposite party shall pay the insurance claim of the complainant with 12% interest p.a. from the date of complaint till realisation.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 29^th day of October 2011.

Sd/- A. Rajesh,President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :: Nil

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